August 2011 CE Site code # 107200E-1211 Pediatric Emergencies Objectives by Mary Ann Zemla, RN Reviewed/revised by Sharon Hopkins, RN, BSN, EMT-P To view on the Advocate Condell website visit: www.advocatehealth.com/condell/body.cfm?id=422
Date of CE presentation: August 2011 Topic: Pediatric Emergencies Behavioral Objectives: Upon successful completion of this module, the EMS provider will be able to: Describe components and purpose of the pediatric assessment triangle. Discuss pediatric vital signs. Describe the purpose of the Wong Baker Faces pain scale. Discuss airway assessment in the pediatric population Discuss use of the IO needle in the pediatric population. Identify possible causes of pediatric arrests. Describe defibrillator pad placement in the pediatric population. Describe the use of an AED in the pediatric population. Review a variety of EKG rhythms. Participate in medication calculation practice. Describe treatment per Region X SOP of the pediatric patient in a variety of rhythm disturbances. Describe the dosage and route for medications used in pediatric situations. Demonstrate use of a length based resuscitation tape (ie: Broselow Tape) to identify equipment and medication to use in a critical event. Demonstrate correct technique per AHA CPR guidelines for a neonate and infant. Actively participate in case scenarios for the pediatric population. Successfully complete the post quiz with a score of 80% or better. References: Aehlert, B. PALS Pediatric Advanced Life Support. Revised 2nd Edition. Elsevier. 2007. American Academy of Pediatrics, 2nd Edition. Pediatric Education for Prehospital Professionals. Jones and Bartlett. 2006. American Heart Association 2010 Guidelines for CPR and ECC. 2010. Dietrich, A.M., Shaner, S., Campbell, J. Pediatric Trauma Life Support for Prehospital Care Providers 3rd Edition. ITLS. 2009. Rahm, S. Pediatric Case Studies for the Paramedic. AAOS. Jones & Bartlett. 2006. Region X SOP, March 2007, Revised May, 2008.
Pediatric Assessment Triangle The across the room assessment Appearance Work of breathing Group Practice #1 Circulation to skin 2 year old presents with shortness of breath. Mom states son has had a 3 day history of productive cough and runny nose. Child holding blanket & intently watching your movements while being held in mother s arms. RR appears to be within normal limits for age with no evidence of work of breathing. Chest expansion appears equal. Skin is pink Appearance - Work of breathing - Circulation - Is child sick/unstable? Or not sick/stable? Wong Baker Faces Pain Scale
Group Practice #2 An 8 month old infant presents with a cough, clear nasal discharge, and difficulty breathing. Mom states the infant has had a cold for the past 2 days. She is concerned because his breathing is different today and he has been feeding poorly. You note the infant appears tired & limp in mom s arms. Color is dusky. Respiratory rate is rapid & shallow. You note nasal flaring and intercostal & subcostal retractions. Appearance - Work of breathing Circulation Is child sick/unstable? Or not sick/stable? What action is necessary? Intraosseous Insertion 6 H s Hypovolemia give 20 ml/kg, repeat up to 60 ml/kg Hypoxia oxygenate Hydrogen ion acidosis ventilate Hyper/hypokalemia obtain history, check EKG for tall peaked T waves Hypothermia keep covered and warm Hypoglycemia most common metabolic problem in neonates 5 T s Tablets /drug overdose what has the child gotten in to? Tamponade, cardiac Tension pneumothorax check breath sounds, if bagging is there resistance? Equal rise and fall of chest wall? Thrombosis, coronary ACS Thrombosis, pulmonary embolism
Rhythm Review Identify the following rhythm strips 1. 2. 3. 4. 5.
Practice Calculating mg Problem #1 Pt weighs 44 pounds Administer 1:10,000 Epinephrine 0.01 mg/kg Problem #2 Pt weighs 56 pounds Administer Amiodarone 5 mg/kg Problem #3 Pt weighs 75 pounds Administer Benadryl 1 mg/kg How many mg does the calculation give to administer? Problem #4 Pt weighs 25 pounds Administer Versed 0.1 mg/kg
Drug Calculation Practice Formula #1 X ml = desired dose (mg) x vol on hand (ml) dose on hand (mg) Formula #2 mg on hand = mg ordered ml on hand x ml Practice Calculating Volume to Draw Up Use mg answers from previous problems Problem #1 Administer 0.2 mg. Epinephrine 1:10,000 packaged as 1 mg/10ml Problem #2 Administer 125 mg. Amiodarone packaged as 150mg/3ml Problem #3 Administer 34 mg. Benadryl packaged as 50mg/ml How much would you really administer to a patient per SOP? Problem #4 Administer 1.1mg.Versed packaged as 5mg/5ml
Group Practice #3 A 7 year-old girl is having difficulty breathing. You find the child sitting upright and leaning forward, supported by arms, mouth open. She is aware of your presence but unconcerned. You note nasal flaring, suprasternal retractions and use of intercostal muscles. You hear audible loud wheezes without a stethoscope. Color is pale. Caregiver states a history of asthma. A neighbor visited about 1 hour ago to show them a new cat. Respirations 38 and labored Pulse 140/minute B/P 94/62; capillary refill < 2 seconds Skin pale, warm & dry Speech limited to 2-3 word sentences Absent breath sounds bilaterally in bases, diminished throughout remaining lung fields Appearance - Work of breathing Circulation - Is child sick/unstable? Or not sick/stable? Case Scenario Small Group Practice Break into smaller groups. Each group to be assigned a scenario. Present your scenario to the group through discussion and role playing skills. All members need to take an active role and demonstrate at least one technique. You may use any available resources to answer your questions under the Instructions (texts, blackberries, SOP s, power point, websites, presenter, etc). Differentiating ST from SVT in the Pediatric Population Sinus Tachycardia SVT Rate Usually <220 infants; <180 children Usually >220 infants; >180 children Regularity Varies with activity Constant Onset/ termination Gradual Abrupt P waves Visible, normal Often indiscernible History Explanation can be given for rate Hx non-specific in absence of cardiac hx
Case Scenario #1 You receive a frantic 911 call from a mother screaming her 4 year-old is not breathing. Upon entering the home, the child is lying supine and motionless on the living room floor Child was electrocuted; is no longer in contact with the source Appearance unconscious, unresponsive Work of breathing none Circulation cyanotic S stuck a pin into an electrical outlet A none M vitamins P bilateral ear tubes 6 months ago L breakfast E playing in house, stuck a pin into the outlet First EKG Rhythm: EKG Rhythm after several rounds of CPR and medications: Instructions: Develop a general impression Determine your course of action Be prepared to role play the call to the group Demonstrate skills Performing CPR on a child Broselow tape Drawing up/preparing and administering medications Explain the rationale for medication used including dosing, and side effects/precautions
Case Scenario #2 911 call received for a 7 month-old infant with nausea and vomiting. Mother states child became ill earlier in the day and has had several episodes of vomiting and diarrhea. Child now refusing pedialyte and water. Appearance- Conscious, has weak cry, is listless Work of breathing - Airway open, respirations rapid and unlabored Circulation of skin - Pale S sudden onset this morning A- none M-vitamins; Motrin (last dose last night) P-none L-last night E-was fine yesterday afternoon. Started with fever last night (101.50F); Has vomited x3, diarrhea x5 episodes B/P not attempted P 190 R 50 SpO 2 97% room air Blood glucose - 90 Rhythm Strip Instructions: Develop a general impression Determine your course of action Be prepared to role play the call to the group Demonstrate skills Broselow tape Obtaining IV access Calculating and preparing fluid resuscitation Providing supportive ventilations via BVM Explain the rationale for interventions used and side effects/precautions
Case Scenario #3 You receive a 911 call from a mother stating her 6 month-old is having trouble breathing. Upon arrival you are met at the door with the mother holding the infant. The infant is in obvious respiratory distress, is coughing, and has a runny nose. Appearance -Conscious, decreased interactiveness Work of breathing - Nasal flaring; open mouth breathing, retractions evident Circulation - Pale, dry S Mother states the patient suddenly stopped breathing, turned blue; when she picked him up, the infant started to breathe A- none M- vitamins P- umbilical hernia repaired shortly after birth L-took half a bottle this morning; took longer than normal for intake E-cough and runny nose for 2 days; worsening today; low grade fever 100.5 o F B/P not obtained (<3 years-old) P 200, regular R 50 SpO 2 93% Blood glucose 76 Rhythm strip: Instructions: Develop a general impression Determine your course of action Be prepared to role play the call to the group Demonstrate skills Broselow tape Securing the airway Regular Albuterol nebulizer and in-line delivery Supportive ventilations via BVM Explain the rationale for interventions used and side effects/precautions of interventions (airway, ventilating, med)
Case Scenario #4 You receive a 911 call for a 6 year old with an altered level of consciousness Child is sitting in mom s lap, conscious but not interactive Appears confused Appearance - Conscious but confused, sleepy Work of breathing - Respirations deep & rapid Circulation Skin pale, dry, poor turgor S Confused, tachycardic, tachypneic A- none M-none P- none L-last night E-Ill past few days. Mother thought it was the flu. Complained of stomach ache last night. Mother comments that the child has been very thirsty lately and going to the bathroom a lot. Mother states he may have lost weight recently. B/P 88/56 P 130 weak, regular R 40/minute and deep SpO2 97% Blood glucose high Instructions: Develop a general impression Determine your course of action Be prepared to role play the call to the group Demonstrate skills Obtaining a blood sugar sample on a child Broselow tape Drawing up/preparing and administering fluids List causes of altered mental status in the pediatric patient (ie: AEIOUTIPS) File: CE, EMS; CE Packets; 2011 ; August Handout Pediatric Emergencies
Pre-Quiz Paramedic And Basic Level From August 2011 CE Material Pediatric Emergencies Name Date 1. List the 3 components of the Pediatric Assessment Triangle. 2. What is the difference between respiratory distress and respiratory failure? Resp distress: Resp failure: 3. Is bradycardia an early or late sign of deterioration in a critically ill pediatric patient? 4. If a blood pressure cuff is too large for your patient, how will it affect your blood pressure results? 5. At what age is it appropriate to obtain blood pressures in the pediatric population in the field?
Aug 2011 Peds Pre-quiz 6. List at least 4 methods of non-pharmacological pain control measures. 7. List at least 4 signs or symptoms that a very young patient may be experiencing hypoglycemia. 8. Answer the questions in the columns for use of an AED in the following populations: Neonate Can an AED be used? Do you need a peds dose attenuator (special peds pads)? Can you use an adult AED? Infant Child Adult 9. Describe characteristics of sinus arrhythmia. When is it normally observed? 10. Describe neonatal ( not infant) CPR techniques. Compression depth: Ratio compressions to ventilations: Compression rate: If spontaneously breathing, rate to deliver ventilations via BVM: What is the goal heart rate to achieve when supporting ventilations? File: CE, EMS; CE Packets; Quizzes; 2011; August Pre-quiz